Ilizarov instrument and principal of fixation technique of wires in tibia and safe zones in tibia , distraction principal

1. ILIZAROV
ILIZAROV
Presented by
Dr. ASHISH CHAUHAN
JUNIOR RESIDENT

2. HISTORY-Gavriil Abramovich Ilizarov(1921-1992)
The MAN, The Creator, The Teacher
MAGICIAN OF KURGAN
Transosseous Osteosynthesis"
(Springer Verlag, 1992, 800 pages)
professor Ilizarov wrote: "Our
research in medicine, biology and
engineering has led to the evolution
of more than 800 unique, highly
effective methods of treatment
Tension- Stress Effect" and
formulated it thus: "slow, steady
traction of tissues caused them to
become metabolically activated,
resulting in an increase in the
proliferative and biosynthetic
function

3. Instrumentation
Primary components :
Elements used to correct skeletal deformities.
Eg. Ring wire, wire fixation bot and buckles, pin and pin
clamps
Secondary component :
Element necessary for assembly of frame.
Eg. Rods, plates, support, post, hinge, washer, sockets,
bushing, bolts and nuts

4. Rings
Principle component
Made of stainless steel or
carbon fiber to bear high
stress ( up to 150 kg)
Internal diameter measures
from 80-240 mm.
80-140mm used in paediatric
age group
150-240 mm used in adults

5. FUNCTIONS
Support transfixation of ilizarov, olive wires and
half pins
Builds a fixator frame connecting two or more
rings
Props up frame’s supplementary parts.

6. HALF RINGS

7. FULL RINGS
Advantages:
Slightly lighter in weight
Does not require nut and
bolt to connect half rings
It has 6 more holes to
work or to connect
hinges and small plates
DISADVANTAGES:
Post op if their is swelling
full ring must be removed
with diamond saw.

8. FIVE EIGHTH RING
. ADVANTAGES:
. less restricted
joint as compared
to full ring
. More room for
introduction of
cross k wires as
compared to half
ring
. For special care
of soft tissue

9. HALF RING WITH CURVED ENDS
. Used in deltoid
region

10. Arches
Larger diameter than half
rings.
Extra holes for use at the
level of proximal femur or
humerus
Does not limit joint motion
original ilizarov arches
transfixed with k wires
at the level of GT so
there are chances of
sciatic nerve injury

11. ITALIAN ARCHES
Modification of original
arches by dr cattagni
Fixed with Schanz pins
bicorticaly in prox.
Femur
Reduced risk of sciatic
nerve injury
Known as Italian arches

12. BOLTS

13. Bolts
Hexagonal head of 10mm
Threaded shaft of 6mm diameter.
Pitch of thread is 1 mm
Length of 10, 16 and 30 mm used.
Have longitudinal holes or slot just below head to fix
wires to the ring or other components of the frame
It is uses to connect the threaded socket and bushing
through the rings, for connecting plate, for fastening rods
and half pins through socket aperture.

14. NUTS

15. Nuts
Diameter-6 mm
Height- 6,5 and 3 mm
Pitch of thread-1mm
So 1/4th
turn four times per
day is recommended
distraction compression rate.
Turn of nut is used as driving
force in ilizarov system.
.

16. FUNCTION OF NUTS
Function:
Tighten the connecting bolt
Stabilized connecting rods
Driving vector for distraction- compression
movement
Lock socket and bushing onto threaded rod
Secure hinge clearance and gap on threaded
rod
Affix pulling wire of distraction device

17. Buckle
Combine a plate with 2 fixed threaded rod with two hole
plate held together with 2 nuts.
A longitudinal groove hold a wire to ring like a slotted
bolt.
Allow mechanical derotation or angular correction

18. RODS
6 mm stainless steel
threaded rods
Come in 10 lengths 60-
400 mm
Share the same pitch 1
mm
Increase in length of rod
decrease its bending
potential thus at least 4
rods are used to
connect 2 rings

19. Rods
6 mm thick stainless steel rod is main connector
4 rods at equidistant are used to connect 2 neighboring
rings.
By turning nuts we can fix rods to the frame
We can produce desired compression or distraction
needed
Rods are machined so that thread causes 1 mm
translational along its longitudinal axis with each
complete 360˚ revolution of nut
Slotted cannulated rod with 2x2 mm slot and length of 20
thread, act as pulling device.

20. Telescopic rod
Hollow rods used as support and connecting elements of
the rings.
Base is machined to accept 10 mm open end wrench.
Head have 2 holes :
1st
for threaded rod
2nd
for bolt to lock rods
Provide stability when log distance spanning is required
between rings
Now hollow tube may contain slotted window with
graduated metric marking on one side.

21. Plates
Use to reinforce ring fixator
Short plates are used as extension of rings
Long plates used to reinforce large frames during bine
fragment transport
Plates with threaded rod used to support a hinge as well
as a frame
Twisted plates used to connect two components
positioned at right angle to one another
Curved plates used to increase circumference of half ring
and connect two half ring

22. SHORT PLATE

23. LONG PLATE

24. MALE Support
Type- male and female post
Male post : threaded
projection fixed with nut
Female post- threaded hole
fixed with bolt
Function:
Third wire can be connected
to post
Can also work as hinge
Can be connected to other
part of apparatus to provide
additional stability
Wire can be tensioned

25. FEMALE POST

26. Hinge post
Have supporting base
wit two flat surface
matching the standard
10 mm wrench
Important function is
correction of angulation
Type- male and female
hinge post

27. WASHERS

28. Washer
Washer is used to raise a wire fixation bolt to the wire
that does not sit directly on ring
Types : simple, slotted and conical
Slotted washer : allow wire fixation on one side in special
circumstances
Conical washer : act as swivel for connecting rings or
plates which are not parallel.

29. Tensioners
Used to tension wire to an exact force, thus
improvising stability for entire bone frame construct
Types : dynamometric and standard wire tensioner
Wire should be tensioned from 50-130 kg
Amount of tensioning depends upon :
Weight of patient
Local bone quality
Treatment plan
Local frame construct
Standard wire tensioner not calibrated and
cumbersome to use.

30. Threaded socket & bushing
Threaded rod
interconnect threaded
rods
It stabilized two rings
together
Hole on side, can be
used for threaded rod in
horizontal direction

31. BUSHINGS
Bushing is 12 mm
long spacer with
smooth
longitudinal hole
that provide free
motion of
threaded rod
length wise.

32. Dynamometer
Parts of dynamometer :
Handle for applying pressure
Dynamometer scale
Fixed jaw
Mobile jaw
Using of dynamometer :
Rotate handle anti clockwise until wire get
inside
Engage the fix jaw to the ring
Rotate handle clockwise until desired
tension is achieved
Tighten the nut at desired tension
Rotate handle anti clockwise to loosed the
wire

33. Ring positioning
Rings are main component
Types :
Main proximal frame supporting ring : It bears weight of entire
construction. Located 3-5 cm away from joint
Stabilizing frame supporting ring : may be stationary or
moveable. Located 3-5 cm away from joint
Pushing pulling ring : moveable ring used for compression or
distraction. Located 3-5 cm distal to fracture-osteotomy-
nonunion site
Reference ring : used as reference for supporting rings or
distraction-compression rings. It corresponds to apex of bone
regulation
Connecting rings : used for application of special forces in
transverse or oblique direction for correcting deformities.

34. Assembly of circular fixator
Major considerations :
Stability of fixation of the frame to the bone
The prevention of gross bone fragment motion
Ability to manipulate bone and to perform necessary fragment
movement such as straightening, bending, distraction,
compression, rotation and combination of these movement
Construction of frame can be done in advance or during
surgery
Important aspect of frame assembly:
Ring positioning
Ring inclination
Ring orientation
Ring level
Spacing between skin and ring

35. Spacing between skin and ring
At the narrowest gap space of at least 3 cm should be
maintained between inner curve of ring and skin
Achieved in 3 ways :
Limb measured in 2 plane and largest diameter is
considered. Add 6 cm to this diameter which provide you
size of ring
Attach most anticipated size and seek a space of 3 cm
Use plastic template.

37. Loosely attached slotted fixation bolt at entrance
site guide k-wire and prevent deflection during
introduction and drilling
One wire one hole to prevent incorrect positioning
Push wire manually to bone before drilling

38. K WIRES
ADVANTAGES OF K WIRES
When drilled into the tissue
destroy very little compact
bone and marrow
When tensioned properly it
dampens vibration and
prevent soft tissue and
bony destruction because
of elasticity
After removal penetration
holes are very small
Small diameter holes less
external contamination

39. Olive wires
Metallic bead in wire.
Function :
Interfragmentary
compression
Increasing stability of
the construct
Gradual distraction
Translation of fragment

40. K wires V/S PINS
K wires are more elastic in comparison to pins ( pins are
stiff structures)
2-3 k wires when transfixed to bone under proper traction
can replace the linear force of a stiff pin but some
elasticity still remaining .
Advantages of elasticity :-
Elasticity prevents soft tissue destruction
Generate more rapid callus formation and maturation

41. 7 CARDINAL RULES OF K WIRE
1. Entry and exit point
should be predetermined
by the surgeon to to
reduce soft tissue injury
2.Entrance and exit point
of the k wire must be at
least 2 cm from the
major blood vessel
( surgeon should mark
the trajectory of artery on
the skin with pen )

42. Rules of k wire fixation
3. K wire is positioned
according to ring plane
either proximal -
proximal or distal-distal
for this slotted fixation
bolts are useful as a
guidance system

43. 4
K wire must be
introduced slowly
with a low power drill
of 30-40 rpm
Low speed wire
introduction permits
moving a side such
soft tissue structures
like blood vessels
and nerves their by
avoiding serious
injury.

44. 5.
Entrance and exit site
skin must be
supported with fingers
to support the exact
point of wire
penetration
In a planned
distraction skin should
be pushed toward the
site of corticotomy

45. 6
Prior to passing wire each
muscle should be stretched
maximally to its functional
length to prevent contracture

46. 7. Rule of one wire one hole
Multiple holes resulting
from incorrect wire
positioning destroy
compact bone through
mechanical damage and
though burning

47. SURGICAL TECHNIQUE
Wire is introduced into the
skin with simple puncture
as soon as feel the cortex
slightly move k wire up and
down to feel the slope of
bone
To avoid bending of wire
trajectory should be straight
and gripped ate entry point
with a wet gauge.
Wire should be drilled
transmedullary not
transcortical
( transmedullary wires are
more stable)

48. WIRE POSITIONING IN THE RING
Ideal angle -90 degrees
If angle is 30 degree or
less there are chances of
side- side displacement
of bone
If between 30-45 degree
there are high chances of
ring shearing movement

49. Ring should be well
stabilized to bone for that
wire should not be brought
down to the ring, ring
should be brought upto
the wire using washer,
support, post or hinges.
When greater load is
required, 3 wire can be
transfixed to one ring.

50. Wire should be fixed as
close to the ring
connector
Closer the wire less
axial load they will bear
and less chances of
wire breakage.

51. AFFIXING WIRE TO RING
If the wire is situated in
middle of hole
cannulated bolt is used
If the wire is near the
edge of hole slotted bolt
is used
If the wire in between to
holes buckles must be
used

52. WIRE TENSIONING
Quality of bone healing and
regelation depend upon strength of
wire tension
Range of wire tensioning 50-130 kg.
Tensioning strength of wire on half
ring – 50-70 kg
Tensioning strength of offsite wire-
50-80 kg
Tensioning strength of single wire on
ring-100 kg
Tensioning strength of 2-3 wires on
ring in young patient- 110 kg each
ring
Tensioning strength of 2-3 wires on
ring in adult patient- 120-130 kg each
ring
Tensioning strength of wire with olive
stopper- 100-110 kg.

53. SAFE ZONES


55. 

56. 

57. 

58. 

59. 

60. Corticotomy
It is low energy osteotomy of
cortex preserving local blood
supply to both periosteum
and medullary canal
Types : monofocal & bifocal
Ideal corticotomy :
Long oblique
Metaphyseal in situation
No comminution
No disruption of endosteal &
perisoteal blood supply
Fixed in anatomical position
with gap <2 mm

61. MONOFOCAL CORTICOTOMY
Osteotomy at one level
INDICATIONS -
1.lengthening up to 5 cm
2. Stimulation of local blood
circulation without significant
lengthening as in
pseudoarthrosis and non union
3. Gradual correction of bone
deformity

62. BIFOCAL CORTICOTOMY
Osteotomy at two levels
Indications:
1. Lengthening upto 12-14 cm
2. Simultaneous lengthening at
one level and deformity correction
at other level
3. Stimulation of osteogenesis in
metabolic disorder

63. BONE DISTRACTION
SPEED-1 mm per day
RHYTHEM- 0.25 per 6
hourly
DISTRIBUTION OF
FORCE -resistance of
surrounding tissue to
distraction can be easily
overcome with even
distribution force

64. ACCORDION TECHNIQUE
Used in hypertrophic and
normotrophic non union
Alternative compression
distraction forces are applied
to stimulate bone neogenesis
Compression for 10 days
distraction upto 10-20
➡️
mm( compression distraction
both @0.25 mm twice a
day) stop procedure for 7-
➡️
10 days compression of
➡️
7-10 mm distraction of 5-7
➡️
days radiography to check
➡️
for bone formation

65. Stages of Ilizarov treatment technique
1. Fixator application and following latency period of 4-7
days
2. Period of distraction/ compression (1-4 months
depending on case)
3. Period of immobility and fixation of bone position (usually
twice period of distraction/ compression)
4. Discontinuation of distraction-compression and frame
dynamization 15-20 days to fixator removal
5. Period of immobilization with a cast or brace

66. THANKS
THANKS